LATERAL VIOLENCE AND BULLYING IN THE WORKPLACE
I.
STATEMENT OF POSITION
Lateral violence and bullying has been extensively reported and documented among
healthcare professionals, with serious negative outcomes for registered nurses, their
patients and health care employers. These disruptive behaviors are toxic to the
nursing profession and have a negative impact on retention of quality staff.
Horizontal violence and bullying should never be considered normally related to
socialization in nursing nor accepted in professional relationships. It is the position of
the CENTER for American Nurses (The CENTER) that there is no place in a
professional practice environment for lateral violence and bullying among nurses or
between healthcare professionals. All healthcare organizations should implement a
zero tolerance policy related to disruptive behavior, including a professional code of
conduct and educational and behavioral interventions to assist nurses in addressing
disruptive behavior.
II.
PURPOSE
The purpose of this position statement is to support the registered nurse to work in an
effective and collaborative manner with other nurses, healthcare professionals, and
administrators and to develop appropriate policies, codes of conduct and educational
programs to eliminate disruptive behavior from the workplace. The CENTER also
provides the Registered Nurse with guidance in managing disruptive behavior to
include lateral violence and bullying in the workplace.
III.
DEFINITIONS
Bullying and lateral violence represent two types of disruptive behavior in the
workplace.
Bullying is an “offensive abusive, intimidating, malicious or insulting behaviour, or
abuse of power conducted by an individual or group against others, which makes the
recipient feel upset, threatened, humiliated or vulnerable, which undermines their
self-confidence and which may cause them to suffer stress. Bullying is behaviour
which is generally persistent, systematic and ongoing” (Task Force on the Prevention
of Workplace Bullying, 2001, p. 10). Bullying is associated with a perpetrator at a
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higher level or authority gradient, for example, nursing supervisor to staff nurse
(CENTER for American Nurses, 2007).
Lateral violence (Griffin, 2004; Rowell, 2007; Stanley, Martin, Michel, Welton, &
Nemeth, 2007), horizontal violence (Dunn, 2003; Farrell, 1997; Hastie, 2002; Longo
& Sherman, 2007) and horizontal hostility (Bartholomew, 2006; Thomas, 2003)
are terms used to describe the physical, verbal or emotional abuse of an employee.
Within nursing, lateral violence has been defined as nurse to nurse aggression. This
violence can be manifested in verbal or nonverbal behaviors. The ten most common
forms of lateral violence in nursing are: “non-verbal innuendo,” “verbal affront,”
“undermining activities,” “withholding information,” “sabotage,” “infighting,”
“scapegoating,” “backstabbing,” “failure to respect privacy,” and “broken
confidences” (Griffin, 2004).
Disruptive Behavior is behavior that interferes with effective communication among
healthcare providers and negatively impacts performance and outcomes. This type of
behavior is not supportive of a culture of safety.
Culture of Safety is characterized by open and respectful communication among all
members of the healthcare team in order to provide safe patient care. It is a culture
that supports “organizational commitment to continually seeking to improve
safety”(Institute of Medicine, 2007, p. 15).
Workplace bullying “Workplace bullying is repeated inappropriate behaviour, direct
or indirect, whether verbal, physical or otherwise, conducted by one or more persons
against another or others, at the place of work and/or in the course of
employment, which could reasonably be regarded as undermining the
individual’s right to dignity at work.” (Task Force on the Prevention of Workplace
Bullying, 2001, p. 5).
Verbal abuse – a disruptive form of behavior involving verbal communication that is
associated with horizontal violence and bullying. Cox described verbal abuse as “any
communication a nurse perceives to be a harsh, condemnatory attack upon herself or
himself professionally or personally” (1991a, p. 32). Such abuse can include: silence,
backbiting, gossip, and passive aggressive behavior (Rowe and Sherlock 2005 p.
243).
IV.
HISTORY
The culture of the healthcare setting has been historically populated by images of the
nurse as a “handmaiden” in a patriarchal environment (Kelly, 2006, p.23). The
balance of power has not been in the nurse’s favor. Organizations fashioned to be
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hierarchical have not fostered a culture of professional collegiality, nor have they
advanced the role of nursing. Too often, nurses have acquiesced to a victim mentality
that only facilitates a sense of powerlessness. Nurses have reported concern about the
lack of action taken by supervisors in addressing horizontal violence in the workplace
(Farrell, 1997; Stanley et al., 2007).
While not directly addressing bullying or horizontal violence, Kramer (1974)
described the “reality shock” occurring for new graduates when they encountered
differences in their perception of what nursing could be and the actual reality of the
workplace. Kramer suggested that “reality shock” can manifest as hopelessness and
dissatisfaction, which is a prelude to conflict in the workplace (p. 9). Today, bullying
is an international phenomenon not limited to the healthcare arena, and abuse can also
occur between professions. The phrase “nurses eat their young,” has been used to
describe the negative behaviors directed toward new nurses (Rowe & Sherlock,
2005). Griffin (2004) described the vulnerability of newly licensed nurses as they are
socialized into the nursing workforce; lateral violence affected their perception of
whether to remain in their current position.
Sofield and Salmond (2003) found that primarily physicians, then patients, and
patients’ families were responsible for most of the verbal abuse towards nurses. Onethird of respondents expressed they would consider resignation in response to verbal
abuse; it was concluded that nurses lacked the skills to deal with the verbal abuse and
perceived themselves as powerless to change organizational response (Sofield &
Salmond, 2003). Cox found the most frequent source of verbal abuse was physicians,
and in descending order patients, families and peers, supervisors and subordinates
(1991). The turnover attributed to verbal abuse was 24 percent for staff nurses and 25
percent for nurse managers (Cox, 1991b) Cook, Green and Topp (2001) found that
perioperative nurses encountered verbal abuse by physicians. However, Rowe and
Sherlock (2005) reported that nurses in particular were the most frequent source of
verbal abuse towards other nurses. Patients’ families were the second most frequent
source, followed by physicians and then patients (Rowe & Sherlock, 2005).
In 2004, The Institute for Safe Medication Practices published a survey on workplace
intimidation. Almost half of the 2,095 respondents, which included nurses,
pharmacists and other providers, recalled being verbally abused when contacting
physicians to question or clarify medication prescriptions; intimidation had played a
role in either not questioning a concerning order or seeking ways not to directly
confront the prescribers. While physicians and prescribers used intimidating
behaviors, however they were not the only intimidating healthcare providers (Institute
for Safe Medication Practices, 2004a).
In a hostile environment, communication is hindered and this can affect quality of
care and patient safety (Joint Commission on Accreditation of Healthcare
Organizations, 2002). Healthcare providers report intimidation does alter
communication and negatively impacts patient care and safety (Institute for Safe
Medication Practices, 2004). Healthcare professionals facing intimidation may
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sometimes choose to abdicate their advocacy role to avoid intimidating behaviors,
impacting patient safety. The Institute for Safe Medication Practices survey (2004)
revealed that more experienced nurses were more likely to encounter intimidating
behaviors; differences in intimidating encounters were not appreciably different in
terms of gender but females were more likely to ask another colleague to talk with the
intimidator for them. The organization’s effectiveness in handling intimidation was
viewed less favorably by those nurses and pharmacists with more years of practice in
that facility (Institute for Safe Medication Practices, 2004a)
V.
Implications of Not Managing Lateral Violence and Bullying
Conflict in the workplace results in serious negative outcomes for registered nurses
and other healthcare professionals, organizations, and patients. The Joint Commission
(2007) acknowledges that unresolved conflict and disruptive behavior can adversely
affect safety and quality of care. Additionally, healthcare organizations are grappling
with a continuing nursing shortage today and it is projected to grow worse as nurses
retire (American Association of Colleges of Nurses, 2007). Bullying and lateral
violence have a negative impact on the ability of the nursing profession to retain both
new and long-term colleagues.
VI.
Organizations’ Response to Disruptive Behavior
A number of nursing organizations have issued statements regarding the detrimental
effect of disruptive behavior on both patients and nurses and have called for solutions
to address the problem (American Association of Critical-Care Nurses, 2004; AORN,
2003, 2007; International Council of Nurses, 2006; National Student Nurses
Association, 2006). The American Nurses Association Code of Ethics for Nurses
speaks to “improving health care environments and conditions of employment
conducive to the provision of quality health care” (American Nurses Association,
2001, p. 20). Additionally, the Joint Commission (2007) has proposed a revision in its
standards for disruptive behavior, identifying manifestations of abuse and violence in
the workplace and providing avenues for ending this phenomenon which will take
effect in 2009. It is imperative, then, that definitive action be taken to address the
problem of workplace violence and its impact on health professionals and patients.
The development of zero tolerance for abuse in the work place is a recommended
strategy to address disruptive behaviors (American Association of Critical-Care
Nurses, 2004; Institute for Safe Medication Practices, 2004b; Ramos, 2006; Tabone,
2001).
VII.
SUPPORTIVE MATERIAL: EVIDENCE-BASED & BEST PRACTICES SOLUTIONS
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Nursing recognizes the need for cultural change to eliminate the effects of disruptive
behavior including lateral violence and bullying at the personal, organizational,
national and international levels. Suggested improvements include interdisciplinary
collaboration, communication and opportunities for education and training to address
disruptive behavior by physicians (Rosenstein, 2002). In a cognitive rehearsal
strategy proposed by Griffin (2004), nurses were taught to delay automatic thoughts,
and respond differently through empowerment strategies to address lateral violence.
Gerardi (2004) described the use of mediation techniques to identify conflict early
and develop a plan to resolve it by listening, reframing the concerns raised,
identifying commonalities and clearly defining decisions. Developing a critical mass
of diverse professionals trained in conflict management can not only reduce lateral
violence and bullying, but it can also assist with other potential conflict situations,
such as, error disclosure issues and process reviews.
The Institute of Safe Medication Practices (2004b) suggested organizational
strategies: development of a multidisciplinary group that will survey staff about
behaviors, develop educational opportunities, establish a standard method for
collaborative communication and zero tolerance for intimidation, in addition to being
models for and rewarding positive behaviors.
VIII. SUMMARY
The CENTER for American Nurses recognizes that lateral violence and bullying in
the workplace is a serious problem. It is imperative that the profession of nursing
address this problem to improve the recruitment and retention of nurses. The efforts
to improve patient care are inextricably linked to the work environment of nurses
(Institute of Medicine, 2004). Disruptive behaviors of healthcare providers are not
conducive to a culture of safety. The evidence is clear that disruptive behaviors such
as lateral violence and bullying are serious problems that negatively impact the work
environment of nurses. This problem is broad reaching and has clear implications in
the current and future projected shortage of nurses, as well as the safety and quality of
patient care. It has an impact on the ability of the profession to recruit new members
and the ability of healthcare organizations and other employers to retain nurses.
IX.
RECOMMENDATIONS
The CENTER for American Nurses recommends the following strategies to
eliminate disruptive behavior (lateral violence and bullying):
Nurses
• Nurses and nurse leaders, managers and supervisors adopt and model
professional ethical behavior
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•
•
•
•
Recognize and appropriately address bullying and disruptive behavior in the
workplace through enhanced conflict management and conflict resolution
Reflect on your own behavior and communicate respectfully with each other
Participate in collaborative interdisciplinary initiatives to prevent abuse.
Work to ensure the mission, vision and values of their workplaces that are
reflective of the Code of Ethics for Nurses (American Nurses Association,
2001) and standards set by the profession, in order to eliminate disruptive
behavior (lateral violence and bullying).
Employers/Healthcare Organizations
• Implement zero tolerance policies that address disruptive behaviors (lateral
violence and bullying) and indicate such behaviors will not be tolerated. The
organizations should adopt zero tolerance policies that include appropriate
investigation and due process necessary to provide adequate safeguards to
nurses and others who are accused of lateral violence or bullying. (See
appendix for sample policy).
• Promote a Culture of Safety that encourages open and respectful
communication among all healthcare providers and staff (The Joint
Commission, 2007).
• Provide support to any individual impacted by lateral violence and/or
bullying.
• Provide education and counseling to victims and the perpetrators of horizontal
violence and bullying.
Nursing Continuing Education and Academic Programs
• Disseminate information to nurses and students that address conflict and
provide information about how to change disruptive behavior in the
workplace.
• Implement continuing education programs related to bullying and lateral
violence and interventions to address such behaviors.
• Develop educational programs regarding bullying and strategies on how to
recognize and address such disruptive behavior.
• Develop and implement curricula that educate nursing students on the
incidence of disruptive behaviors including lateral violence and bullying,
along with steps to take to eradicate this behavior.
Nursing Research
• Continue to research the contributing factors and the process of lateral
violence and bullying behaviors.
• Build on previous and current studies while seeking to explore innovative
interventions on how to eliminate manifestations of disruptive behaviors
• Evaluate the efficacy of promising strategies in eliminating disruptive
behaviors (lateral violence and bullying) from the workplace.
.
The CENTER as a Nursing Policy Maker
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•
•
XI.
Support policy, development of legislation, regulations and standards that
promote a culture of safety for patient care and discourage all forms of
disruptive behavior, including lateral violence and bullying.
Continue its work to assure that nurses influence legislative initiatives,
accreditation standards and policies through active participation in the policy
process (International Council of Nurses, 2000).
CONCLUSION
The CENTER for American Nurses maintains there is no place for lateral violence or
bullying in professional practice environments. Bullying, lateral violence and all
forms of disruptive behaviors have a negative impact on the retention of nursing staff
and the quality and safety of patient care. Nurses, individually and collectively, must
enhance their knowledge and skills in managing conflict and promote work place
policies to eliminate bullying and lateral violence. It is imperative that health care
organizations and health care professionals approach the elimination of lateral
violence and or bullying from a context of ethically-based respect, in the interest of
optimal patient care. The CENTER will continue to work to educate the nursing
workforce, the healthcare industry and consumers about the importance of
eliminating lateral violence and disruptive behavior in all practice settings.
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Appendix
Policy and Procedure
Subject:
ZERO TOLERANCE FOR ABUSE
Effective date:
Policy: It is the policy of ________________ (Hospital or Health Care System) to
promote a work environment that is pleasant healthful, comfortable, free from
intimidation, hostility, and free of abuse, verbal or physical, that could interfere with
work performance and the delivery of safe quality patient care within the
_________________________ (Hospital or Health Care System). The
_____________________ (Hospital or Health Care System) has Zero Tolerance for
behavior that is verbally or physically abusive and which could interfere with work
performance and the delivery of safe quality patient care.
Employees, contracted individuals, or providers with hospital privileges who report in
good faith that they have experienced verbal or physical abuse will not be subject to
discrimination, retaliation, or termination for reporting concerns to their supervisor or to
the administration of the ______________ (Hospital or Health Care System).
Upon any report of alleged abusive behavior ________________________ (Hospital or
Health Care System) will work to resolve the report through its procedure for dealing
with abuse allegations.
Procedure: System procedures may vary based upon the individual hospital procedures
for resolving unacceptable behavior. However, the procedure at a minimum should:
• Outline what a person should do to report abuse.
• State what specific protections can be expected for the reporting individual from
discrimination, retaliation, or termination.
• Identify how the organization will make decisions and the steps it will take to
remedy the issue once abuse is reported.
• Provide information about expected organization action when employees,
contracted individuals, or persons with practice privileges in the facility are found
to have engaged in abusive behavior.
• Indicate how the reporting person will receive information about the outcome of
the abuse report.
Adapted with permission from the Texas Nurses Association (2007)
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Additional Resources
The Workplace Bullying Institute
www.bullyinginstitute.org
Bully Busters
www.bullyinginstitute.org
Occupational Safety and Health Administration (OSHA)
www.osha.gov
National Institute for Occupational Safety (NIOSH)
www.cdc.gov.niosh
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